Dr Sasmoyo Risk Stratification & Management of STEMI

8/11/2019 Dr Sasmoyo Risk Stratification & Management of STEMI

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Sasmojo WiditoMalang

2014


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Work experience

1994-1997 Community Health Center of Sumbawa,

West Nusa Tenggara

1998-2005 Cardiovascular Resident,

University of Airlangga, Surabaya

2005-now Cardiovascular Specialist,

Dr. Saiful Anwar Teaching Hospital, Malang

2005-now Cardiovascular Lecturer, School of Medicine,University of Brawijaya, Malang

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Training & studying

1986-1993 University of Sebelas Maret, Surakarta,

Medical Doctor

1998-2004 University of Airlangga, Surabaya,Cardiologist

2007 National Cardiovascular Center Harapan Kita,

Jakarta,

Basic Invasive Training

2011-2012 Binawaluya Cardiac Center, Jakarta

Advanced interventional cardiovascular

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Sequence of Ischemic Heart Disease

Risk Factor

Endothelial dysfunction

CAD

Ischemia

AnginaSilent

MI

ArrythmiasLost of muscle

Remodeling

Progresif dilatation

Heart FailureDeath

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ManagementBefore STEMI

4

1 2 3 4 5 6

Onset of STEMI- Prehospital issues- Initial recognition and management

in the Emergency Department (ED)- Reperfusion

Hospital Management- Medications- Arrhythmias- Complications- Preparation for discharge

Secondary Prevention/Long-Term Management

Modified from Libby. Circulation 2001;104:365,

Hamm et al. The Lancet 2001;358:1533 and Davies. Heart 2000;83:361.

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Naghavi et al. Circulation 2003;108:166484

Normal coronary arteryno atherosclerosis, widelumen

Atherosclerotic plaquehas caused 60 - 70 %stenosis

A thrombus is well-established, only 3 smalllumens remain

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capsul

core


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SymptomRecognition

Call toMedical System

ED Cath LabPreHospital

Delay in Initiation of Reperfusion Therapy

Increasing Loss of Myocytes

Treatment Delayed is Treatment Denied

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healthcare providers should assist patients,

making anticipatory plans for timely recognition and response toan acute event

taking chew nonenteric-coated aspirin (162 to 325 mg) and 1nitroglycerin in response to chest pain promptly

If symptoms are unimproved or worsening 5 minutes after 1 dose,the patient should be instructed to call EMS immediately

Family members, close friends should be enlisted as reinforcementfor rapid action when the patient experiences symptoms ofpossible STEMI

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preexisting bias that a heart attack should present dramaticallywith severe, crushing chest pain

one third of patients with MI experience symptoms other thanchest pain

reasoning that symptoms will be self-limited or are not serious

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attribution of symptoms to other preexisting conditions

fear of embarrassment should symptoms turn out to be a false

alarm

reluctance to trouble others unless really sick

preconceived stereotypes of who is at risk for a heart attack

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lack of knowledge of the importance of rapid action,

unavailability of EMS

unavailability of reperfusion therapies

attempted self-treatment with prescription and/ornonprescription medications

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STEMI

Clinical syndrome

Symptoms: myocardial ischemia

ECG: ST elevation Lab: release of biomarkers of myocardial necrosis.

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Heart attack warning signs

Chest discomfortpressure, squeezing, fullness, or pain in the center of chest

Discomfort in one or both arms, back, neck, jaw, orstomach

Shortness of breath

often comes with or before chest discomfort

Breaking out in a cold sweat, nausea, or light-headedness

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Heart attack warning signs

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Diagnostic ST elevation

New ST elevation at the J point in at least 2 contiguous leads of 2mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2V3 and/or of 1 mm (0.1 mV) in other contiguous chest leads orthe limb leads.

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RBBB QRS complex durationprolonged

V1Monophasic R, rsr, Rsr, RSr, RSR, rSr,rSR, rsR, qR.ST depression (discordant)

V6Wide S, RS complex

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RBBB, STEMI anterior

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LBBBV1, V2, V3 QS, rS, with ST elevation (discordant)

I,aVL,V5,V6 monophasic R, with ST depression (discordant)

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Diagnostic ST elevationLBBB with STEMI

Sgarbossa criteriaI,aVL,V5,V6 ST elevation 1 mm, concordant QRS complex (score 5)

V1,V2, or V3 ST depression 1 mm (score 3)

V2-V4 ST elevation 5 mm, discordant QRS complex (score 2)

Score of 3 had a specificity of 98% for STEMI, but a score of 0 did

not rule out STEMI

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LBBB with STEMI: Sgarbossa criteria

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Diagnostic ST elevation ST depression in 2 precordial leads (V1V4) may indicate

transmural posterior injury

STEMI Inferoposterior

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Clinical findings:Shock with clear lungs, elevated JVP

Kussmaul sign

Hemodynamics:

Increased RA pressure (y descent)

Square root sign in RV tracing

ECG:

ST elevation in R sided leads

Echo:

Depressed RV function

Rx:Maintain RV preload

Lower RV afterload (PA---PCW)

Inotropic support

ReperfusionV4RModified from Wellens. N Engl J Med 1999;340:381.

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Multilead ST depression with coexistent ST elevation in lead aVR:left main or proximal left anterior descending artery occlusion

Hyperacute T-wave changes: early phase of STEMI, before thedevelopment of ST elevation

Baseline ECG abnormalities other than LBBB (e.g., paced rhythm,LV hypertrophy, Brugada syndrome) may obscure interpretation.

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Echocardiography: provide focal wall motion abnormalities,facilitate triage in case with ECG findings that are difficult tointerpret.

If doubt persists, immediate referral for invasive angiography maybe necessary to guide therapy in the appropriate clinical context.

Cardiac troponin: preferred biomarker of MI.

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Some of the independent predictors of early deathfrom STEMI include

Age, Killip class,Time to reperfusion, Cardiac arrest,

Tachycardia, Hypotension,

Anterior infarct location, Prior infarction,

Diabetes Mellitus, Smoking status,

Renal function, Biomarker findings

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Thrombolysis In Myocardial Infarction (TIMI) riskscore

http://www.mdcalc.com/timi-riskscore-for-stemi

GRACEhttp://www.outcomesumassmed.org/grace/acs_risk/acs_risk_content.html

Risk assessment is a continuous process, should be repeatedthroughout hospitalization and at time of discharge.

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http://www.mdcalc.com/timi-riskscore-for-stemihttp://www.outcomesumassmed.org/grace/acs_risk/acs_risk_content.htmlhttp://www.outcomesumassmed.org/grace/acs_risk/acs_risk_content.htmlhttp://www.mdcalc.com/timi-riskscore-for-stemihttp://www.mdcalc.com/timi-riskscore-for-stemihttp://www.mdcalc.com/timi-riskscore-for-stemihttp://www.mdcalc.com/timi-riskscore-for-stemihttp://www.mdcalc.com/timi-riskscore-for-stemihttp://www.mdcalc.com/timi-riskscore-for-stemihttp://www.mdcalc.com/timi-riskscore-for-stemi


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Regional systems of stemi care and goals for reperfusion therapy

Strategies for shortening door-to-device times

Prehospital Fibrinolytic Therapy

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CABG, coronary artery bypass graft; DIDO, door-indoor-out; FMC, first medical contact; LOE, Level of Evidence;

MI, myocardial infarction; PCI, percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction.


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Performance of PCI is dictated by an anatomically appropriateculprit stenosis

Cardiogenic shock or severe heart failure initially seen at a non

PCI-capable hospital should be transferred for cardiaccatheterization and revascularization as soon as possible,irrespective of time delay from MI onset.

Angiography and revascularization should not be performedwithin the first 2 to 3 hours after administration of fibrinolytic

therapy


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Back ground studies:

CAPTIM (Comparaison de lAngioplastie Primaire et de laThrombolyse) trial,

WEST (Which Early ST-Elevation Myocardial Infarction Therapy)

trials USIC (Unit de Soins Intensifs Coronaires) Registry

Swedish Registry of Cardiac Intensive Care

Advantages: lower STEMI mortality rates

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Effort:

Training for EMS officer in rural areas

Funding for necessary equipment.

Prehospital fibrinolysis is more widespread in some regions of Europeand the United Kingdom.

further research into the implementation of prehospital fibrinolytic

strategies to reduce total ischemic time.

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Timing of FibrinolyticTherapy

Benefits are well established,with a time-dependent reductionin both mortality and morbidity

rates during the initial 12 hoursafter symptom onset


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When interhospital transport timesare short, there may be advantagesto the immediate delivery offibrinolytic therapy versus any

delay to primary PCI for patientswith STEMI and lowbleeding risk who present withinthe first 1 to 2 hours of symptom

onset


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Benefit from fibrinolytic therapy inpatients who present 12 hours aftersymptom onset has not beenestablished


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Consensus:consideration should be given toadministering a fibrinolytic agent insymptomatic patients presenting 12 hours

after symptom onset with STEMI and alarge area of myocardium at risk orhemodynamic instability if PCI isunavailable


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Choice of Fibrinolytic Agent

Fibrin-specific agents are preferred when available. Adjunctive antiplatelet and/oranticoagulant therapies are indicated, regardless of the choice of fibrinolytic agent.


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Contraindications andComplications WithFibrinolytic Therapy


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Contraindications andComplications WithFibrinolytic Therapy


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Fibrinolytic Therapy When There Is anAnticipated Delay to PerformingPrimary PCI Within 120 Minutes ofFMC


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Fibrinolytic Therapy When There Is anAnticipated Delay to PerformingPrimary PCI Within 120 Minutes ofFMC


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Indications for fibrinolytic therapy when there is a >120 mindelay from FMC to primary PCI

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Adjunctive AntiplateletTherapy With Fibrinolysis


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Adjunctive AnticoagulantTherapy With Fibrinolysis


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Assessment of ReperfusionAfter Fibrinolysis

The relatively sudden and complete reliefof chest pain coupled with 70% STresolution is highly suggestive ofrestoration of normal myocardial bloodflow.

Complete (or near complete) ST-segmentresolution at 60 or 90 minutes afterfibrinolytic therapy is a useful marker of apatent infarct artery


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Assessment of ReperfusionAfter Fibrinolysis

The combination of 50% ST resolution andthe absence of reperfusion arrhythmias at 2hours after treatment predicts TIMI flow 3in the infarct artery.

Lack of resolution of ST elevation by atleast 50% in the worst lead at 60 to 90minutes should prompt strongconsideration of a decision to proceed withimmediate coronary angiography andrescue PCI.


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Indications for Transfer forAngiography AfterFibrinolysis


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COR, Class of Recommendation; FMC, first medical contact; HF, heart failure; LOE, Level of Evidence;

MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction.PKB. Malang. 2014

Primary PCI in STEMI


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COR, Class of Recommendation; FMC, first medical contact; HF, heart failure; LOE, Level of Evidence;

MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction.PKB. Malang. 2014



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COR, Class of Recommendation; FMC, first medical contact; HF, heart failure; LOE, Level of Evidence;MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction.

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COR, Class of Recommendation; FMC, first medical contact; HF, heart failure; LOE, Level of Evidence;MI, myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction.

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Use of Stents in Primary PCI

Balloon angioplasty without stent placement may be used inselected patients.


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Antiplatelet Therapy to SupportPrimary PCI for STEMI

The recommended maintenance dose of aspirin to beused with ticagrelor is 81 mg daily.


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Antiplatelet Therapy to SupportPrimary PCI for STEMI


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Anticoagulant Therapy to SupportPrimary PCI


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Anticoagulant Therapy to SupportPrimary PCI


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Posthospital management

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MedicationsAntithrombotic therapiesBeta blockersACE inhibitors/ARBs/aldosterone antagonistsStatins

Physical activity & cardiac rehabilitationPhysical ActivityCardiorespiratory fitness (MET capacity)


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Risk factor modification & lifestyle interventionsSmoking cessationDiet/nutrition

Management of comorbidities

Overweight/obesityLipidsHypertensionDiabetesHF

Arrhythmia/arrhythmia risk


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Psychosocial factorsSexual activityGender-specific issuesDepression, stress, and anxietyAlcohol use

Culturally sensitive issues


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Provider follow-upCardiologistPrimary care providerAdvanced practice nurse/physician assistantOther relevant medical specialists

Electronic personal health recordsInfluenza vaccination


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Socioeconomic factorsAccess to health insurance coverageAccess to healthcare providersDisabilitySocial servicesCommunity services


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Electro-cardiogram


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StressTest

Electro-cardiogram


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StressTest

CoronaryAngiography

Electro-cardiogram


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PublicHealth

perspectiveof CHD

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6thAsian Interventional Cardiovascular Therapeutics, 2010

Patients communities:


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PublicHealth

perspectiveof CHD

Patients, communities:Take care of yourselfKnow of treatment optionsSeek treatment early

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Patients, communities:


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PublicHealth

perspectiveof CHD

Family physician:Learn of options that exist for CAD patientsRisk factors modifications


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PublicHealth

perspectiveof CHD


Media:Educate patientsMonitor results & compliance


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PublicHealth

perspectiveof CHD


Cardiologist:Initiate early treatments: anticoagulants,antiplatelets, -blockers, narcoticsMaster triage, and transfer



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PublicHealth

perspectiveof CHD




Interventional cardiologist:Expert in short D2B interventions

,Take care of yourselfKnow of treatment optionsSeek treatment early

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PublicHealth

perspectiveof CHD






Hospital:Provide exceptional ED, CVL, andCCU services

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PublicHealth

perspectiveof CHD






Hospital:Provide exceptional ED, CVL, andCCU services

Politicians and Leaders:Allocate appropriate resources the next patient maybe you or yourloved one

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Documents

Dr Sasmoyo Risk Stratification & Management of STEMI